Options for Driving Outcomes and Patient Reported Outcome Measures

Author: Orca Health

September 1, 2020

The Industry Shift

Within the healthcare industry, there has been a significant shift from volume-based, fee-for-service (FFS) payment to value-based, performance-dependent payment. Programs have been created to assess and facilitate patient-centered, high-quality care that improves health and reduces costs across the healthcare system. One of the easiest ways to understand the implications of this shift is “no outcome, no income.” Healthcare providers are in a position where they must collect patient-reported outcomes to ensure payment integrity from private and public payers, as well as drive meaningful improvements to patient care. 

Origin of Reported Outcomes

The rise of patient-reported outcomes as quality measures for healthcare effectiveness started in the recent past. The Healthcare Effectiveness Data and Information Set (HEDIS) quality reporting system has been in existence for decades. Other associations like LeapFrog and Quality Improvement Organizations (QIOs) have also made their mark. Notably, the most significant entrant into the quality measurement and required reporting space has been Medicare. 

Measuring quality performance on the physician level had been a slow-moving change, but evolving Medicare programs paired with advancing technology has driven significant advancements in the past decade. What began as the Physician Quality Reporting Initiative (PQRI) in 2006, turned into the Physician Quality Reporting System (PQRS) and the Value-Based Modifier (VBM) for group practices after the passing of the Affordable Care Act in 2010.  

In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA), a significant piece of legislation that focuses on healthcare quality and value of care delivery by improving access and implementing payment reform. MACRA enabled Medicare to reward high-value, high-quality physicians with payment increases, while at the same time, reducing payments to clinicians not meeting performance standards. 

This legislation led to the creation of the Quality Payment Program (QPP) in 2017 with a vision of supporting patients and clinicians in making their own decisions about health care “using data-driven insights, meaningful quality measures, and innovative technology”. The Merit-based Incentive Payment System (MIPS) combines the PQRS, VBM, and Electronic Health Record (EHR) Incentive Program into one, performance-based system. Payment adjustments are based on a final score of four categories: Quality, Promoting Interoperability (PI), Improvement Activities, and Cost.

PROM Solutions for Providers

Providers can choose different types of outcomes measurement solutions. Some focus on the collection of patient satisfaction metrics, while others solicit responses to the long list of license bearing or free specialty-specific outcome measures. The modes of patient interactions and surveys employed by physicians are evolving with advances in technology, accessibility, and integration capabilities. Traditional paper-based or telephone surveys require a laborious clerical process to solicit results and process findings. Furthermore, a majority of patients disregard the surveys and fail to complete them. Online or email-based surveys tend to have better response rates. Automated survey platforms that integrate with HIE or EMR systems also improve effectiveness in collecting and analyzing data. These can help increase response rates without adding to the administrative burden already faced by clinics. 

How to Drive Outcomes?

Patient compliance with physician instructions is one of the primary determinants of a good outcome. A recent study cited below found that healthcare consumption decreased the risk of premature death by ten percent. The most potent factor in promoting health/avoiding premature death is Individual Behavior. Clear physician instructions, coupled with patient compliance, create the best possible outcomes.

Scholars have noted the difference in health literacy between physicians and patients. Patients with low health literacy often have a difficult time navigating their care and acquiring needed information. They also face compliance challenges. In the study, the authors note that even though most of the population reads at the 8th-grade level, 1/5 of patients read below the 5th-grade level.

Consequently, speaking slowly and simply is the best strategy for physicians to improve patient comprehension and compliance with medical advice. Another recommendation is to have information written in a clear and concise form. (1)

Determinants of Patient Outcomes

Electronic Technology in Patient Education

Newer research on the same topic explored the impact of electronic technology on patient education. These researchers noted that 1/3 of the U.S. adult population has limited health literacy. The authors recommend providing written materials at the 5th-6th grade level and summarizing to three key points. They also promote the use of visual aids, graphs, pictures, and other non-text based communication methodologies. These communication media are more effective in enhancing patient understanding and compliance. (2)

Written information provided to patients is also frequently disregarded or misunderstood. Forms and consents are confusing because each is text-heavy and written at an advanced grade level. Therefore, it is reasonable to conclude that patient compliance can be significantly affected by a lack of patient understanding of physician instructions and clinical education.

3D Animation Improves Patient Understanding

In randomized controlled studies, 3D Animation has been shown to improve patient understanding of the risks and benefits of a procedure. Therefore, if a part of the anatomy can be animated in a 3D environment, and the procedure can be displayed in the same way, patient understanding increases.

More than merely grabbing attention, studies show that 3D animations are more effective than text and 2D illustrations alone in communicating health information. Medical animation, compared to printed materials, improves patient understanding of procedures and potential complications and increases trust in medical professionals. Additionally, the use of these tools reduces anxiety and increases the feeling of readiness for the procedure, according to the results of a randomized controlled trial published in The Surgeon, a German journal. (3)

In the same study, the authors also noted that hospitals and health care systems incorporating 3D animation into their online marketing see higher levels of patient engagement and an increased perception of quality care. “Patients are partners with physicians in their care. Education helps make them better informed and makes that partnership stronger. When we are the provider of that information, it reflects positively on us.” (3)

The Benefits to Multisensory Learning

Multisensory learning involves more than one sense in the education experience. For example, if a physician narrates a 3D video of anatomy, and the patient can touch the screen of the iPad and rotate the image, that patient has involved three senses in the learning episode. “Multisensory training protocols, as opposed to unisensory protocols, can better approximate natural settings and, therefore, produce greater and more efficient learning.”(4) 

The Role of Caregiver-Patient Interactions

To effectively drive outcomes, patient compliance with medical advice is imperative. Therefore the interaction between the patient and practitioner must be addressed. Consequently, viewing patient education as an intervention is appropriate. A cogent intervention “involves the patient and practitioner reaching a mutual understanding of each other’s explanatory models of illness and disease. It, therefore, takes into account the patient’s ideas, concerns, and expectations at all stages of the clinical interview, from gathering information through problem formulation to decisions about management.” This research showed that satisfaction with care was higher in the intervention (cogent explanation) group in 17 of 27 (63%). When describing a procedure, the specific interventions (explanation complexities) frequently altered the process of interactions (significantly in 73%, 22 of 30 trials). Principal outcomes favored the intervention group in 74% of trials (26 of 35), reaching statistical significance in 14 (40%). Positive effects on health outcomes achieved statistical significance in 44% of trials (11 of 25); negative effects were uncommon (5 of 25, 20%). (5)

Communications Best Practices

  1. Use 3D animation to educate patients.
  2. Narrate the animations in real-time, and supplement with notes and instructions.
  3. Ensure that the patient can review the communications after the visit.
  4. Give patients a reason to interact, e.g. a direct message from their physician.

Conclusion and Recommendations

Education and communication modalities help providers bridge potential and real education gaps and deficits in unprecedented ways. The development of 3D content and delivery systems that allow patients to interact with their health care diagnosis and treatment plans on their own time is a significant augmentation to available solutions on the market today.

Practitioners should consider the impact of inefficiency and potentially ineffective patient education on their workflow and productivity, patient and surgical retention rates, and most importantly, their outcomes performance. Engaged patients are more likely to have better outcomes, and consequently, ensure the financial stability of the enlightened practice.

References:

  1. Safeer, R. M.D., CareFirst BlueCross BlueShield, Baltimore, Maryland, Keenan, J. ED.S., The Keenan Group, Inc., Ellicott City, Maryland. "Health Literacy: The Gap Between Physicians and Patients". Am Fam Physician. 2005 Aug 1;72(3):463-468.
  2. Hersh, L M.D, Salzman, B. MD., Snyderman D. MD, Thomas Jefferson University, Philadelphia, Pennsylvania. "Health Literacy in Primary Care Practice." Am Fam Physician. 2015 Jul 15;92(2):118-124.
  3. "3D Animation Improves Patient Understanding." http://www.prweb.com/releases/2012/10/prweb10041889.htm
  4. Shams L., Seitz A., (2008). Benefits of multisensory learning.Trends in Cognitive Sciences, 12(11), 411-417. Impact Factor: 21.97
  5. Watson, Philip WB, McKinstry, Brian. "A systematic review of interventions to improve recall of medical advice in healthcare consultations", J R Soc Med June 1, 2009 vol. 102 no. 6 235-243
  6. Medicare Program; CY 2018 Updates to the Quality Payment Program; and Quality Payment Program: Extreme and Uncontrollable Circumstance Policy for the Transition Year https://storage.aanp.org/www/documents/QPP-Year-2-Executive-Summary.pdf